Friday, November 30, 2007

How to Cope with Pain is now offering a monthly Pain-Blog Carnival during the last week of every month, to include each month's best posts. November's carnival is now posted. New bloggers are always welcome to contribute.

In honor of the American tradition of Thanksgiving which was celebrated last week, this month's Pain-Blog Carnival theme is thankfulness. I'm thankful for the great articles which were submitted and are here for you today. Enjoy!

Fighting Fatigue writes about the spirit of the holiday. "One thing that's helped me deal with being chronically ill is being able to look at the bright side of the situation and find things that I'm still thankful for, even when life looks not-so-great sometimes." And she challenges us to keep our own gratitude journal.

CRPS/RSD A Better Life shares an inspiring video of Alissa, a young girl with CRPS. She's had a remarkable recovery, and supportive family, friends, and dedicated therapists who guided her along the way.

Migraine Chick writes Thank Heaven for Little Things about facing the holidays with chronic pain, and finding there are still things to be thankful for, even if they're the little things that are only important to you.

Somebody Heal Me writes about a change in perspective in her post, Being Thankful for 'Bad' Luck. "I've learned that everything is exactly as it should be. I'm so thankful for this gift. Things in my life may not always be fair or desirable. But we never know whether something is good luck or bad luck because we don't (we can't) see the whole picture. And once you let go of the desire to label things that happen in your life, there's such freedom and the potential for great happiness."

Laurie at A Chronic Dose shares that while there will always be sickness and unexpected complications, this is a time to ignore what isn't working right and what we can't do or can't have. Instead, focus on everything that is going our way. Her post is Giving Thanks Recap (Straw Included).

Lisa at Chronic Illness & Pain Support with Lisa Copen writes in Counting the Blessings Hidden in Illness that finding ways to be thankful can be difficult when one lives with chronic illness. "But if we step back and notice all the little things that happen in our lives - when we were blessed instead of given more stress - it's easy to see just how thankful we can be!"

Matthias at The Neurotopian writes a post of thanks to all scientists who have the courage to speak out under difficult circumstances and made life better for all of us. And he shares a video of one of his favorite scientists, V. S. Ramachandran, "a brilliant scientist who's done more to help cure chronic pain than anyone else on the planet."

Keep Working, Girlfriend asks, Do you want to hear Happy Thanksgiving? Responding to holiday good cheer can be difficult when you live with chronic pain. Here are some ways to handle these situations.

Psychology of Pain shares a post about a man who found a cure for his pain… after a long ordeal. Lee Nelson is a business executive who suddenly developed a very severe, intractable headache. After years of dogged persistence, he eventually found a physician who identified the source of the pain and another whose surgical intervention was able to eliminate it. Nelson and his wife have much to be thankful about and credit their own intellectual curiosity, motivation, and financial resources, and the diagnostic and surgical skills of some physicians (while criticizing the inaction of others).

Counting Sheep, written by a nurse anesthetist, recounts a night she spent covering an obstetrics service. "It's about two women in pain; it's about interventions; and it's about what is fair."

Sufferer of RSD shares a way to express your thankfulness and to support someone who contributes everyday to pain organizations. Alecia Grafton, a woman with CRPS, will donate 5% of all Christmas sales from her gift basket business, Heart Filled Baskets, to RSDS.org. Sufferer of RSD writes "I commend her for being able to take a gift that she has and use it to support RSD/CRPS."

Monday, November 26, 2007

Time after time, properly conducted scientific studies have proved that homeopathic remedies work no better than simple placebos. So why do so many sensible people swear by them? And why do homeopaths believe they are victims of a smear campaign? Ben Goldacre follows a trail of fudged statistics, bogus surveys and widespread self-deception.

Phantom Limb Pain May Be Reduced By Simple Mirror Treatment

ScienceDaily (Nov. 24, 2007) — Phantom limb pain occurs in at least 90% of limb amputees according to the research. Jack W. Tsao, M.D., D.Phil., assistant professor, Department of Neurology at the Uniformed Services University of the Health Sciences (USU) conducted a sham-controlled trial using mirror and imagery therapy in patients who have had a foot or leg amputated.

Health Sciences (USU) conducted a sham-controlled trial using mirror and imagery therapy in patients who have had a foot or leg amputated.

Twenty-two patients at Walter Reed Army Medical Center in Washington, D.C. were assigned to one of three groups: one that viewed a reflective image of themselves in a mirror (mirror group); on that viewed a covered mirror; and one that was trained in mental visualization.

Eighteen patients completed the study with six in each group, and after one month of treatment 100% of the members in the mirror group reported less phantom pain, while only 17% reported a pain decrease and 50% reported worsening pain in the covered mirror group, and 67% reported worsening pain in the mental visualization group.

The study found that mirror therapy reduced phantom limb pain in patients who had undergone amputation of the lower limbs. Such pain was not reduced by either covered mirror or mental visualization treatments. These results suggest that mirror therapy may be helpful in alleviating phantom pain in lower limbs.

The study, titled “Mirror Therapy for Phantom Limb Pain,” was published in the November 22 edition of the New England Journal of Medicine.

Tuesday, November 20, 2007

Can a patient ever show up at the doctor's office with too much information?

A doctor's essay about medical "Googlers" — patients who research their symptoms, illness and doctors on the Web before seeking treatment — suggests they can. The report, which appeared in Time magazine, was written by Dr. Scott Haig, an assistant clinical professor of orthopedic surgery at Columbia University College of Physicians and Surgeons. He begins with a description of a patient he calls Susan, who seems to be clicking on a keyboard as she speaks to him on the phone. "I knew she was Googling me,'' he writes.

Dr. Haig's disdain for her information-seeking ways becomes quickly evident. He describes the woman's child, whom she brings to the office, as "a little monster'' and notes that the woman soon "launched into me with a barrage of excruciatingly well-informed questions.'' Every doctor knows patients like this, he writes, calling them "brainsuckers.''

Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived. It was a little too much — as if she knew how stinky and snorey I was last Sunday morning. Yes, she was simply researching important aspects of her own health care. Yes, who your surgeon is certainly affects what your surgeon does. But I was unnerved by how she brandished her information, too personal and just too rude on our first meeting.

The problem, Dr. Haig notes, is that patients can have too much information and often don't have the expertise to make sense of it. "There's so much information (as well as misinformation) in medicine — and, yes, a lot of it can be Googled — that one major responsibility of an expert is to know what to ignore,'' Dr. Haig writes.

Dr. Haig's essay, however, has riled patient advocates, who believe patients need to arm themselves with information and take charge of their own medical care. Mary Shomon, who runs a popular thyroid disease blog on About.com, recently highlighted the essay on her site, generating angry responses from readers. Ms. Shomon said she thinks many physicians like Dr. Haig are threatened by patients who use Google and other Internet resources to research their own health questions.

"By condemning Googlers, he made it clear that he's threatened by empowered, educated and assertive patients who do their own research,'' said Ms. Shomon. "He can't handle a patient who talks and doesn't just listen. Good patients…are seen and not heard, right?''

Dr. Haig concludes his essay by confessing that he decided not to treat the woman, whom he described as "the queen of all Googlers.''

I couldn't even get a word in edgewise. So, I cut her off. I punted. I told her there was nothing I could do differently than her last three orthopedists, but I could refer her to another who might be able to help.

In September Randy Pausch, a computer science professor at Carnegie Mellon University, gave his last lecture, telling the audience that he would soon die of pancreatic cancer. But those may not be his last public words after all.

After delivering the talk, Dr. Pausch had planned to enjoy his last days with his family. Instead, Wall Street Journal reporter Jeff Zaslow wrote a column about the unusual lecture, which he described as a "riveting and rollicking journey through the lessons" of Dr. Pausch's life, and the professor became a media sensation.

Dr. Pausch had spoken of his belief that people ultimately will impress you if you wait long enough and his view that kids should be allowed to draw on their bedroom walls. A video of the talk quickly spread over the Internet: the lecture was translated into German, even Mandarin. Dr. Pausch was asked to appear on "Oprah" and "Good Morning America." (I also wrote about Dr. Pausch on this blog.)

Apparently publishers are convinced the public wants to hear more. Today, the New York Post reports that in a frenzy for rights to a book based on Dr. Pausch's lecture, co-authored by Mr. Zaslow, bidding has reached nearly $7 million. The proposed book reportedly will tell the stories behind the wisdom Dr. Pausch dispensed that day.

To understand the fuss over one professor's final lecture, check out the talk for yourself. Here's the original Wall Street Journal article, which includes a video excerpt, as well as a follow-up story written by Mr. Zaslow. If you have time, watch Dr. Pausch's inspiring hour-long lecture in its entirety. You can download the video or find a full transcript on his home page.

There is one undeniable fact about chronic pain: More often than not, it is untreated or undertreated. In a survey last year by the American Pain Society, only 55 percent of all patients with noncancer-related pain and fewer than 40 percent with severe pain said their pain was under control.

But it does not have to be this way. There are myriad treatments — drugs, devices and alternative techniques — that can greatly ease persistent pain, if not eliminate it.

Chronic pain is second only to respiratory infections as a reason patients seek medical care. Yet because physicians often do not take a patient's pain seriously or treat it adequately, nearly half of chronic-pain patients have changed doctors at least once, and more than a quarter have changed doctors at least three times.

In an ideal world, every such patient would be treated by a pain specialist familiar with the techniques for alleviating pain. But "very few patients with chronic disabling pain have access to a pain specialist," a team of experts wrote in a supplement to Practical Pain Management in September.

As a result, most patients have to rely on primary care physicians for pain treatment, obliging them to learn as much as they can about treatment approaches and to persist in their search for relief.

Medications

Most chronic pain patients end up taking a cocktail of pills that complement one another. These are three categories of drugs useful for treating chronic pain:

¶If the pain is not severe, nonsteroidal anti-inflammatory drugs, Nsaids for short, are often tried first. Some, like ibuprofen and naproxen, are sold over the counter. Others, like diclofenac (Voltaren) and celecoxib (Celebrex), are available by prescription. All have risks, especially to the heart and gastrointestinal tract, and may be inappropriate for those prone to a heart attack, stroke or ulcers. Nsaids must not be combined with one another or any aspirinlike drug, but they can be used safely with acetaminophen (Tylenol).

¶Several classes of drugs originally marketed for other uses are now part of the pain control armamentarium — antidepressants, especially the S.N.R.I.'s like venlafaxine (Effexor) and duloxetine (Cymbalta); antiepileptics like gabapentin (Neurontin) and pregabalin (Lyrica); and muscle relaxants like baclofen (Lioresal) and dantrolene sodium (Dantrium). These are often used in combination with specific pain-relieving drugs.

¶By far the most important class of drugs for moderate to severe chronic pain are the opioids: morphine and morphinelike drugs. Patients often reject them for fear of becoming addicted, a rare event when they are used to treat pain. Doctors often avoid prescribing them for fear of addicting patients, being duped by drug abusers or being raided by the Justice Department. Pain societies have established clear-cut guidelines to help doctors avoid such risks, including ways to identify patients who could become addicted.

Many patients and physicians do not know the difference between physical dependence on a drug (withdrawal symptoms result if the drug is abruptly stopped) and addiction (loss of control over drug use, cravings and continued use despite harm). As with other medications, like steroids and antidepressants, patients have to be gradually weaned from opioids to avoid withdrawal symptoms.

For patients with chronic, continuous pain, using a slowly released opioid like oxycodone (Oxycontin), morphine or fentanyl (administered through a skin patch or lozenge on a stick) is preferred. These drugs minimize or eliminate the hills and valleys of pain and reduce the medication patients need.

The usual side effects — sedation, nausea, confusion — soon disappear except for constipation, which can be treated.

Pain specialists also recommend that patients taking slow-release opioids have on hand a fast-acting one like Percocet (oxycodone with acetaminophen) to treat breakthrough pain.

Methadone, a synthetic opioid, is another option for managing chronic pain, especially neuropathic pain, but it has to be taken several times a day. It is metabolized in the liver, along with other drugs that can affect blood levels of methadone.

Other Remedies

Some patients in chronic pain use a technique called TENS, for transcutaneous electrical nerve stimulation, in which pulses of low-intensity electric current are applied to the skin. The theory is that the pulses transmit signals to the brain that compete with the pain signals. Unlike drugs, TENS has no side effects or interaction with drugs, and it can be used at home.

Acupuncture, another increasingly popular treatment for persistent as well as intermittent pain, is thought to work by increasing the release of endorphins, chemicals that block pain signals from reaching the brain. It may be effective in relieving headaches, facial and low back pain, and pain caused by shingles, arthritis and spastic colon.

Guided imagery, meditation, relaxation therapy and hypnosis or hypnotherapy are often useful adjuncts to pain treatment, because they can reduce stress and take one's mind off the pain. Likewise, cognitive behavioral ("talk") therapy can help patients think and behave differently with respect to their pain. Other options include massage and hydrotherapy, the use of hot or cold water to reduce inflammation and promote healing.

Many chronic pain patients can benefit from physical therapy and exercises to strengthen weak supporting muscles and relax tight joints (which for the last two years has helped me control sciatic pain), or occupational therapy to learn new ways of moving, sitting and lying down to reduce irritation of or dependence on painful body parts.

Finally, a mental adjustment may be necessary to improve the quality of life of chronic pain patients, who have to accept that they may always have some degree of pain. Chronic pain tends not to go away, and changes may have to be made both at work and at play. The goals should be to reduce pain to an acceptable level and to learn how not to make it worse.

For Further Information

Here are some groups that can provide information on managing chronic pain:

Monday, November 19, 2007

WASHINGTON - People who get migraines have structural differences in their brains notably in the cortex area that processes pain and other sensory information from the body, scientists said on Monday.

The researchers, whose findings were published in the journal Neurology, said it is unclear whether these brain differences actually cause migraines or are themselves caused by these severe, recurrent headaches.

The researchers performed brain scans on 24 people who had a long history of frequent migraines — about four per month for 20 years — and 12 people who did not get migraines.

The somatosensory cortex — the area of the brain that detects sensations like pain, touch and temperature in various parts of the body — was 21 percent thicker in the people who got migraines compared to those who did not.

The biggest difference was in the part of the cortex responsible for processing sensory information from the head and face, Dr. Nouchine Hadjikhani of Massachusetts General Hospital, who led the study, said in a telephone interview.

Hadjikhani said the study illustrated the seriousness of the migraine. "It has to be taken seriously because it can induce changes in your brain," she said.

Migraines are a type of painful headache commonly accompanied by nausea, vomiting and heightened sensitivity to light and sound. Women are three times more likely than men to experience these headaches. Many people who get them have a family history of migraines.

"The more we understand about the pathophysiology of migraine, the better we will be able to design drugs that work. At the moment, there is no drug for prevention that works well," Hadjikhani said.

Dr. David Dodick, a professor of neurology at the Mayo Clinic who was not involved in the study, said the study shows that migraines are a brain disorder. "And it shows that migraine has some durable, long-lasting morphological or structural changes in the brain over time," Dodick said.

Dodick said he would be interested to know whether people who get migraines less frequently have the same brain changes.

Hadjikhani said one possibility is that repeated, long-term over stimulation of sensory fields in the cortex may cause it to become thicker over time. Another possibility is that people predisposed to migraines already have this thicker cortex, Hadjikhani said.

According to the U.S. National Institutes of Health, researchers suspect migraines are caused by inherited abnormalities in genes that control certain cells in the brain. For many years, scientists had thought migraines were linked to the dilation and constriction of blood vessels in the head.

Dr. Seymour Diamond, executive chairman of the National Headache Foundation and head of the Diamond Headache Clinic in Chicago, said in an interview the findings further confirm that migraines are a neurological disease.

Researchers have seen differences in cortex thickness in other diseases as well. It is thinner, for example, in people with multiple sclerosis, Alzheimer's disease and autism.

Sunday, November 18, 2007

OXFORD, England, Nov. 14 (UPI) -- British researchers said they found a signal from the brain that correlates with the amount of pain a person feels, Nature reported Wednesday.

The signal could be used to refine pain relief techniques that involve using electricity to stimulate the brain, the researchers said.

While single sells have been shown to signal the presence or absence of pain, Morten Kringelbach and his team at University of Oxford identified low-frequency brain waves emanating from two regions deep within the brain when a patient is in pain. The more pain experienced, the longer the waves last, the researchers said.

"It is an objective measure that correlates with a subjective measure," Kringelbach said.

This signal could help refine deep-brain stimulations for patients of chronic pain, he said.

"We could have a stimulator that picks up this neural signature of pain and only starts sending signals at that point," Kringelbach says.

The preliminary study didn't indicate whether the duration of the waves disappeared when painkillers, anesthetics or electrical stimulation are used, said Allan Basbaum, a neuroscientist at University of California-San Francisco.

American commanders in Iraq are urging Pentagon chiefs to authorise the deployment of newly-developed heat wave guns to disperse angry crowds or violent rioters.

But the plea for what senior army officers believe could prove a valuable alternative to traditional firepower in dangerous trouble-spots has so far gone unanswered.

Washington fears a barrage of adverse publicity in the suspicious Muslim world and is concerned that critics will claim the invisible beam weapons were being used for torture.

Now the US military directorate charged with developing non-lethal weapons, which has invested more than a decade developing the Active Denial System (ADS), has launched a concerted effort to convince both the public and its own bosses at the defence department of the device's merits.

"With brand new technology like this, perception is everything," said Col Kirk Hymes, a former Marine artillery officer who heads the directorate.

He added that tests were almost complete and the first ADS, also known as the Silent Guardian, could be deployed early next year if the Pentagon allows. The decision is so sensitive that it is expected to be made personally by the defence secretary, Robert Gates, who sent senior representatives to the demonstrations.

Raytheon, the company contracted to manufacture the prototype, has also received interest from several undisclosed European countries. The machine displayed last week cost about $10 million to build, but the directorate believes that the ADS can be put into production for $2-$5 million (£1-2.5 million) per device.

Col Hymes told observers at a demonstration that the system was a safe and effective alternative to plastic bullets, which can cause injury and sometimes death and are effective only up to 75 metres.

The heatwave weapon can, by contrast, target troublemakers from 750 metres. It works by dispatching high-powered radio waves from a vehicle antenna, similar to a satellite television dish, causing the molecules in a target's skin to vibrate violently, creating a burning sensation.

"We are pretty good at shouting and intimidating people and we have been perfecting the art of lethal warfare since Cain and Abel," he said. "But in places like Iraq we are re-learning that we need a response in the spectrum between shouting and shooting. The ADS provides this."

But he added: "This is not something we want to roll out and deploy and surprise people. We know we need to educate the public."

In fact the development of the weapon only became public after the Sunshine Project - a Texas-based group that campaigns against biological and chemical weapons - pushed for disclosure under the Freedom of Information Act.

The group's director, Edward Hammond, said: "If we are not prepared to use it as a crowd control technique on our own citizens, then we really shouldn't be using it in Iraq either."

Marc Garlasco, a former Pentagon intelligence officer who is senior military analyst for the Human Rights Watch campaign group, was among those invited to feel the device's impact at a recent demonstration.

He said: "If I had the option of being shot by a bullet or this, I would choose this - but still not enough is known about it. This is novel technology. We're talking about bringing science fiction into reality and it's critical to have open discussion."

He added: "People understand what happens when you get shot with a gun, but with the "pain-ray" there's still uncertainty. When it's used, the military is going to have to deal with a public backlash because I'm sure there will be claims of medical problems by the people it's been used upon, real or not."

"We are talking about young soldiers having this in their hands. If we upset the civilian population in Iraq, whether by killing, by torture or by misusing this, it will have a strategic effect on the US's ability to execute effective operations."

Col Hymes said that all ADS operators were given a six- week training course that covered sophisticated crowd control techniques as well as handling the technology.

Wednesday, November 14, 2007

A Lineman in My Bed: Notes on Teeth Grinding

By PAUL VanDeCARR

I grind my teeth at night. Have for years. It’s my secret shame. But now I have the comfort of knowing that at least 8 to 10 percent of the adult population shares my malady.

It’s called sleep bruxism, and it refers to the grinding or clenching of teeth. There’s a waking version, too — an unconscious clenching of the teeth, most often owing to stress — but the origins are different and the effects are seldom anywhere near as bad as during sleep, when certain of the body’s protective mechanisms are turned off. Left untreated, it can cause damage to the teeth and surrounding tissue, headaches and jaw pain.

Bruxism may be at least as old as the Bible, which describes hell as a state where there is “gnashing of teeth.” I might fairly be accused of hyperbole if I reversed the equation and declared that bruxism can turn sleep into a kind of hell. But you get the idea. It’s a real nuisance.

“It’s much like having a large football player standing on the tooth,” says Dr. Noshir Mehta, chairman of general dentistry at Tufts University School of Dental Medicine and director of its Craniofacial Pain Center.

During sleep bruxism, he explained, the upper and lower teeth may come into direct contact as much as 40 minutes per hour, and — for example, on the first molar — with a force of about 250 pounds. Hence the football player. Compare that with normal circumstances, when a person’s teeth make contact for about 20 minutes a day, while chewing, and with only 20 to 40 pounds of pressure.

Even if I wanted a football player in my bed, I certainly wouldn’t want him standing on my teeth. I became aware of his presence the way that many bruxers do. My then-boyfriend told me I woke him up with a dreadful crunching noise that came from grinding; my dentist saw the wear patterns on my teeth and confirmed the diagnosis. Sleep bruxism is not a disease, but a common sleep disorder. It is more prevalent in children, who often outgrow it, and its origins may be different in adults.

“The exact causes are unknown,” said Dr. Gilles Lavigne. If anyone would know, it’s Dr. Lavigne, a professor of dentistry and medicine at the University of Montreal, and president of the Canadian Sleep Society who has published extensively on the topic. In the 1960s, he explains, bruxism was thought to be the body’s response to “malocclusion,” or problems with how the upper and lower teeth fit together; but that theory was discredited for lack of clinical evidence.

Stress was later thought to be the cause, but this failed to explain why not everyone with sleep bruxism was stressed and not everyone with stress ground their teeth. More recent research indicates some relationship of sleep bruxism to neurochemicals like dopamine, but there is still disagreement on how significant a role they play. Dr. Lavigne’s latest studies have identified a pattern of activation in the autonomic nervous system that correlates strongly with sleep bruxism. (He emphasizes that sleep bruxism is not an indicator of neurological disease.)

Whatever underlying causes science may show in time, and they may be several, the more immediate contributing factors for sleep bruxism are better understood. The medical literature shows that stress, smoking, alcohol, caffeine and other factors may set off or worsen the condition.

So what’s a grinder to do? Right away, my dentist suggested fitting me with a mouth guard, a small plastic device that covers some or all of the teeth to protect them against damage, but does not stop the grinding or clenching itself. Unable to afford the $300 price tag at the time, I got an over-the-counter version at the drugstore for $20. “The over-the-counter guards are usually better than nothing,” said Dr. Charles McNeill, director of the Center for Orofacial Pain at the University of California, San Francisco. They protect the teeth, he says, but may also be more likely to induce a chewing response and increase bruxism; they can also cause irreversible damage to the bite, or arrangement of the teeth, and so should be used only temporarily. Guards made by a dentist last longer, fit better and are generally designed to distribute the force of grinding to reduce jaw pain.

Feeling frustrated about my persistent bruxism, I was determined to find a way to stop altogether. Having started grinding during an especially hectic period in my life, I assumed that it was caused by stress. I tried relaxation techniques like yoga, exercise, biofeedback and hypnotherapy. Much as these may have helped my overall health, they didn’t seem to kick the football player out of my bed. Besides, even well after the initial stressor had passed, I was still grinding.

So I did what any reasonable person would do: I turned to drugs. The medical literature on bruxism showed that anti-anxiety medications like buspirone and clonazepam had worked on some patients; buspirone only made me jittery, but clonazepam brought my bruxism to, well, a grinding halt.

“Clonazepam would be a fantastic treatment, but it’s potentially habit-forming; it works too well,” said Dr. Michael Gelb, a clinical professor at the New York University College of Dentistry. “The better the pharmacological treatment works, the more fraught it is with difficulty.”

In two months, I became habituated to the drug and its effect began to diminish. I now use it only occasionally. So much for drugs.

Throughout, I paid attention to which factors seemed to worsen my clenching and grinding, like alcohol and poor sleep habits, and cut back where necessary. On my dentist’s recommendation, I also tried out the NTI-tss device, a hard plastic splint that for some people substantially reduces the intensity of clenching and associated headaches. But I was evidently such an insistent bruxer that I outwitted the principle on which it is based. Finally, I came back to where I started: I got a mouth guard that covers all my teeth, this time custom-fitted by my dentist.

I’d abandoned hope of ending my bruxism until I met a woman recently who stopped 10 years’ grinding after a year of regular acupuncture treatments. I was encouraged enough to try acupuncture myself, and have noticed some improvement after a few months of weekly sessions. Acupuncture has not been clinically proved to cure or calm bruxism, but I’m willing to hang my hopes on anecdotal evidence that suggests it helps.

Though I didn’t know it at the time, I had tried most of the approaches recommended for bruxism, albeit with less success than many people enjoy. Dr. Lavigne, of the Canadian Sleep Society, says people who wake up with headaches or jaw pain may clench or grind their teeth, and should consult their dentist, or doctors at a university-affiliated oral-facial pain center. There, patients may be directed to try some of the techniques I used, or others, and may be assessed for associated conditions like snoring. These approaches may reduce bruxism, but since there is no known cure, only the effects can be reliably treated. In the end, mouth guards are still the best defense.

After all, if you’re going to square off against a football player every night, you need padding.

Tuesday, November 13, 2007

Chronic pain is a family problem. When people experience unrelenting pain, everyone they live with and love is likely to suffer. The frustration, anxiety, stress and depression that often go with chronic pain can also afflict family members and friends who feel helpless to provide relief.

Healthy family members are often overworked from assuming the duties of the person in pain. They have little time and energy for friends and other diversions, and they may fret over how to make ends meet when expenses rise and family incomes shrink.

It is easy to see how tempers can flare at the slightest provocation. The combination of unrelieved suffering on the one hand and constant stress and fatigue on the other can be highly volatile, even among the most loving couples — whose burdens are often worsened by a decline of intimacy.

"Family members are rarely considered by doctors who treat pain," said Dennis C. Turk, a pain management researcher at the University of Washington in Seattle. "Yet a study we did found that family members were up to four times more depressed than the patients."

But pain experts say there is much that family members and friends can do to improve the situation.

Step one is to recognize that chronic pain is not an individual problem. Let the patient know that you are in this together and will fight it together. When the patient is moody and irritable, try not to take it personally.

Step two involves learning as much as you can about the condition and how to treat it. Eliminating the pain may not be possible, but there often ways to reduce it. (See next week's column on treating chronic pain.)

Some of the ideas below were adapted from the American Chronic Pain Association's Family Manual, written by Penney Cowan, the association's founder and executive director.

"Twenty-five percent of the calls we get are from family members looking for help," Ms. Cowan said in an interview last week. "Family members are just as isolated, controlled, frustrated, guilt-ridden and confused by chronic pain as is the person in pain."

Acknowledge your feelings. You may feel guilty about not being able to relieve the distress of someone you love. You may be anxious about financial problems.

You may be distressed by the reactions of other people, who might lack an understanding of chronic pain and suggest that the patient is malingering — faking the pain to avoid work or family responsibilities. At a time when you most need the understanding and support of others, they may seem unsympathetic, even hostile.

But the most common reaction is resentment, over a withdrawal of the patient's affection and sexual intimacy, the unending care required by the patient, the need to add the patient's responsibilities to your own, the decline or loss of a social life and time spent with friends. You may resent having to abandon an enjoyable lifestyle or plans for the future.

If the patient was the family breadwinner and is now unable to work, you may have to find a job and, at the same time, do most or all of the chores at home and care for the patient. Chronic exhaustion can erode your temper as well as your own health.

It is all too easy to react to such feelings in emotionally destructive ways. Owning up to them can help you cope more successfully.

Help the patient stay involved. Chronic pain can rob people of their abilities and force them to be cared for by others, leaving them to feel worthless and guilty over not contributing to the family's welfare. Whether you are the patient's primary or intermittent caregiver, it is important not to contribute to feelings of helplessness.

Encourage patients to participate as fully as possible in family plans and activities, household chores, discussions and decisions. Perhaps they can no longer do yardwork, but they may still be able to help with cooking, setting the table, washing the dishes, caring for children, handling family finances, making phone calls or shopping by phone. Feeling useful can bolster a patient's self-esteem and mood.

"For each action the pain person says he or she can no longer do, point out something he or she can do," the pain association's manual suggests.

Don't become a go-for. Chronic pain patients should be encouraged to do whatever they can do for themselves. It is important for you to know when to step in and when to step back. Recognize the patient's abilities and limitations — consider having an evaluation made by an occupational therapist — and let the patient participate as much as possible in daily activities and self-care.

Communicate. "Open, two-way communication is crucial to dealing effectively with chronic pain," said Dr. Turk, of the University of Washington. "Family members need to know how they can be helpful and what might be hurtful."

Failure to communicate honestly and openly can become a cancer on a relationship, be it with a spouse, parent or child. If chronic pain has disrupted family plans, discuss a reordering of priorities. It may be possible to do more than you think.

You have a right to say that you are tired and need to rest, that you need a break from the routine lest you burn out, and that you need to maintain friendships and pursue enjoyable activities outside the home from time to time.

Likewise, the patient has a right and responsibility to express fear, disappointment, guilt and bad feelings about the behavior of some people, as well as gratitude for the help you and others provide.

Ask periodically what the patient might like to discuss with you or do with you. And try not to rise to the bait when the patient is critical or lashes out at you despite all you do. Most often, you are not really the target. But there may be no one else with whom the patient feels safe to express distress.

Take care of yourself. Enlist all the help you can get from family members and friends. Older children can clean the house and prepare meals. Friends and relatives who offer to help can be given tasks that fit their abilities, even if it is just accompanying the patient to a medical appointment. If they haven't offered, ask.

When necessary, hire others, including neighborhood teenagers, to help out. If you are reluctant to leave the patient home alone, ask a friend or neighbor to stay for a few hours or to look in on the patient every so often so that you can get out for a while.

Don't neglect your own physical well-being. Eat regular meals, get enough sleep and get regular physical exercise. And be sure to keep up with medical checkups and screening exams. If you get sick, you won't be much use to the patient in pain.

This is the second of three columns. Last week's column was an overview of the causes and consequences of chronic pain. Next week: Treatments.

For six years, Lee J. Nelson searched in vain for the cause of the unrelenting headache centered like a bull's-eye above the bridge of his nose.

He consulted nearly 60 doctors, none of whom could find a physical explanation for his pain. He took 100 different medications, but even powerful narcotics brought no more than temporary relief. One doctor who considered his headache a symptom of severe depression suggested electroshock; a specialist at Johns Hopkins proposed last-ditch brain surgery reserved for intractable psychiatric problems.

So the day in 2003 that the Northern Virginia consultant found the answer to his baffling and rare medical problem in a 40-year-old article in the National Library of Medicine, he was overcome. "It described patients just like me," Nelson recalled. "I started crying."

For Nelson, now 55, and his wife, Neta, an executive at a small pharmaceutical company in Herndon, the discovery of that article in a British medical journal proved to be life-changing. It not only provided a diagnosis for a problem that had stumped dozens of specialists, but also described a surgical treatment for the malady that at times had driven Nelson to talk about suicide and his wife of nearly 30 years to contemplate divorce.

While Nelson credits Washington otolaryngologist Sonya Malekzadeh, one of the surgeons who performed an operation similar to the procedure outlined in the article, with saving his life, Malekzadeh regards Nelson's unswerving determination as central to the case she considers among her most memorable.

"He was very persistent," said Malekzadeh, an assistant professor of otolaryngology at Georgetown University who has co-written a paper about the case that has been submitted to a medical journal. "Without his help, I doubt we would have gotten to the end of it," in part because his problem was so uncommon.

Ironically, it was also Nelson's persistence -- reflected in the extraordinary number of doctors he consulted -- that may have prolonged his ordeal. "I saw just about every specialty," he said, many only once because they offered neither "help nor hope."

"As the number got larger and larger I was inadvertently portraying desperation, and that's a red flag," Nelson noted. Doctors tend to regard such patients as having a psychiatric illness or angling for drugs.

One insurance company employee who reviewed his claims asked incredulously, "What is this: a hobby of yours?" Nelson recalled.

His problem surfaced in the winter of 1997 after he recovered from a bad cold. He was left with a sharp headache, which his internist predicted would go away. When it didn't, Nelson saw an otolaryngologist -- the first of six -- who ordered X-rays. They were normal. So were the MRIs and CT scans that followed.

"I kept saying this is an ENT [ear, nose and throat] problem," Nelson said, "and ENTs kept saying there is no evidence of it."

By the time he had seen about a dozen specialists, Nelson and his wife said, doctors had settled on a likely diagnosis: clinical depression.

"I didn't have other symptoms of depression, but as this went on, I did get deeply depressed," Nelson said. He and his wife say they regarded depression as a consequence, not a cause, of his grinding headache.

Nelson underwent psychotherapy and treatment that included numerous medications: anti-seizure drugs, antidepressants and even powerful antipsychotics. He tried biofeedback, acupuncture, hypnosis, Botox injections and a nerve block. He spent a total of six weeks in an inpatient head-pain unit affiliated with the University of Michigan. The couple say they spent tens of thousands of dollars that insurance didn't cover.

The day an ophthalmologist at Johns Hopkins suggested cingulotomy, controversial psychosurgery reserved for intractable psychiatric problems, was arguably "the worst moment," recalled Neta Nelson, who accompanied her husband to many appointments.

"There were times I wondered, 'How long can I do this?' " she remembered. "I cried many nights. There were times I would lie in bed, and just before I fell asleep I'd try and feel what it would be like to be Lee. It was a very difficult period."

Lee Nelson said he had pretty much given up -- "I couldn't tell the story again" -- and planned to file for disability when his wife called Georgetown. Acting on her husband's hunch that the problem was ENT-related, she sought an appointment with an otolaryngologist. Malekzadeh had the next open slot.

Lee Nelson vividly remembers their first meeting in November 2002. "She spent one and a half hours talking with me before she picked up an instrument," he recalled. "I really felt like she was listening."

Malekzadeh remembers the meeting, too. "He was slightly desperate, very unhappy, but he seemed genuine, and he was there with his wife," she recalled. "I didn't think he was crazy or drug-seeking." Her records show he was on a slew of medications at the time: the antipsychotic Seroquel, antidepressants, narcotic pain relievers, allergy medications and nasal steroid sprays.

To her surprise, she was unable to examine the internal anatomy of his nose with an endoscope, a basic procedure that, surprisingly, none of the five other ENTs had attempted. His nasal passages were too narrow for the instrument.

After a variety of medicines failed to open them sufficiently, Malekzadeh told Nelson the best option might be exploratory sinus surgery.

Two surgeries did reduce the pain. Unsure how to proceed, she sent Nelson to the University of Pennsylvania expert who had pioneered endoscopic sinus surgery.

During the examination at Penn, a junior doctor probed a spot inside Nelson's nose, eliciting an immediate response.

"I almost flew out of the chair," Nelson recalled. "I said, 'That's it! That's the pain generator!' The nugget I got was the name of the anatomical structure: the anterior ethmoid neurovascular complex."

The Philadelphia specialist told the couple he didn't think it was germane. Neta Nelson insisted they head to the National Library of Medicine.

There on microfiche they found the 1963 article in the British Journal of Laryngology &amp; Otology. A London surgeon described five cases very similar to Nelson's in which a respiratory infection had caused swelling and compression of the ethmoid nerve in the sinuses, triggering a headache. The only permanent treatment appeared to involve removing bony tissue, thereby freeing the nerve from compression.

"It was pretty classic," said Malekzadeh, who had heard about such a problem during her training but had never seen a case.

On July 1, 2004, she and her colleague Suzette Mikula operated on Nelson.

The pain, Nelson said, gradually lessened. "One day in January 2005 I woke up and realized there was no more pain. That was life-changing." He hasn't had the headache since.

Although elated, Nelson said his recovery "got me into a whole other place of anger and frustration: Why did I have to go through this?"

Malekzadeh considers it "a very gratifying case."

To Neta Nelson, the ordeal illustrates the importance of "never giving up. That's the only take-home message."

Lee Nelson said the experience has radically altered his view of doctors. "I'm very thankful I had the [financial] resources and the gray matter to do what I did," he said. "But I think that a lot of physicians have lost their intellectual curiosity and don't want to work with a patient."

MONDAY, Nov. 12 (HealthDay News) -- Exercise may seem best at preventing illness rather than treating it, but a new study suggests that low-impact physical activity could make an immediate difference for people with one tough-to-treat condition: fibromyalgia.

Women with the little-understood chronic pain syndrome who exercised moderately for four months reported feeling better in a number of ways.

The study didn't say how much more likely the women were to feel better after adopting an exercise regimen, and it's not clear how long the effects last. Still, the findings are promising, said study lead author Daniel S. Rooks, an assistant professor of medicine at Harvard Medical School.

"Exercise should become a part of the treatment plan for people with fibromyalgia," Rooks said. "Basic, simple walking, starting slow and gradually improving, as well as basic flexibility training should be part of what people do to help themselves."

Fibromyalgia causes intense pain and can produce fatigue, insomnia and other symptoms. An estimated 3.5 percent of U.S. women suffer from the syndrome, compared to 0.5 percent of men.

There has been much debate about fibromyalgia, particularly over the role that mental health may play in its progression. Treatment options include pain medications, antidepressants and counseling.

Doctors often recommend exercise as a treatment, but it hasn't been clear exactly what kinds of physical activity should be recommended, Rooks said.

Enter the new study, in which researchers looked at the experiences of 135 women with fibromyalgia from 2002-2004 who were assigned to one of four groups, three of which consisted of exercise regimens.

The researchers gave questionnaires to the women about the state of their fibromyalgia, both before they began the four-month exercise programs and after they completed them. Those who took part in strength training, aerobic activity, and flexibility training -- along with a self-help course on managing fibromyalgia -- reported the most significant improvement, the study found.

Women also improved after taking part in just flexibility and aerobic exercise or in all the three types of activity but without the self-help course. Those who just took the course noted the least improvement.

"Everybody improved if they exercised," Rooks said. "Everybody had some improvement in some aspect of things we were testing."

The study was published in the Nov. 12 issue ofArchives of Internal Medicine.

The exercise levels required in the study, which was funded by the Arthritis Foundation and U.S. National Institutes of Health, were moderate and didn't require sweating, Rooks said. "Part of the message is that you didn't have to work like you were training for the marathon to improve your health," he said. "That was an important message we tried to communicate throughout the study. It was a very well-received message."

There were other benefits of exercise, too. Social function, mental health, fatigue and depression also improved, the study authors wrote. The beneficial effect on physical function of exercise alone and in combination with education persisted at least six months.

Why would exercise be so helpful? "There is a physical part of it and an emotional part of it," Rooks said. "It gives people confidence that they can use their muscles when people have been telling them not to use their muscles."

Dr. Roland Staud, professor of medicine at the University of Florida and a fibromyalgia expert, said exercise is crucial for improvement in patients with chronic pain.

He called Rooks' study well done, if small, and said it shows the value of aerobic exercise in particular. "A lot of fibromyalgia patients think exercise creates more pain, and that wasn't shown here."